Summary

Back in November 2023 I posted here to launch Spiro and raise our first $198k. Two and a half years later this is an update and a fundraiser for the next step.

The short version: we've now reached over-5,900 people with TB preventive medicine, including over 3,000 children under five years old. Our early results have held up well and GiveWell made us a grant last year. Now there's an urgent opportunity in front of us: US funding for community TB contact tracing across half of Sindh province in Pakistan ends this month. The provincial government has invited us to expand our work - taking on those 15 districts and expanding to cover all 30 districts of Sindh, up from the 7 we serve today. To do that we're aiming to raise $512k by the end of July, the most urgent slice of a ~$1.8m gap for 2026–2027. By our own modelling, our work is in the ballpark of something that would meet GiveWell’s bar - around $5,000 per life saved. But if we want to avoid a gap in coverage on the ground after the US pulls out, we’ll need to get funding faster than we can get it from large institutional funders - hence this is a particularly helpful time to get donations from individuals. Here’s our fundraising two-pager. If you'd consider giving, or could introduce us to someone who might, I'd love to hear from you: [email protected].

What Spiro does

Tuberculosis still kills around 1.3 million people a year, and is especially dangerous for young children, but it is treatable and preventable. When someone is diagnosed with TB, the people they live with are at high risk but preventive treatment (“TPT”) cuts the chance of a child’s TB infection becoming active disease by 90%. Unfortunately, TPT coverage for those household contacts is low globally (25%) and even lower in some countries like Pakistan (5%).

Spiro’s "TB Shield" model aims to close that gap by bringing TB screening and medicine into the home - following international guidelines that allow for a simpler screening algorithm for children under 5 year olds. Our field teams visit the households of people diagnosed with TB, screen the family, and — using a telemedicine call so a doctor can assess under-5s on the spot — start eligible young children on child-friendly preventive treatment there and then. We’ve found that removing the barriers for kids to get screened and medicine hugely increases the uptake.

For over-5s (and for anyone symptomatic) we can’t do the screening and medicine at home as they need an x-ray. But we refer people to hospitals and work with those hospitals to make sure they’re trained and equipped to handle these referrals from the community.

Our work is delivered in partnership with provincial TB programmes and public hospitals, building on existing government TB services rather than replacing them.

Progress since our launch

Launched in Pakistan. Rox Heston and I launched Spiro in November 2023. We ran our first pilot at a federal government hospital in Punjab province in Pakistan and were able to screen 89% of kids under-5 when with program costs under $20 per person screened.

Expanded into Sindh province. With funding from GiveWell we were able to launch programs in Sindh province when US-funded TB programming stopped some districts. In September 2025 we launched TB Shield in 19 more public hospitals across 7 districts of Sindh. Due to concerns about drug supply, we unfortunately paused field activities for ~3 months. We relaunched in January 2026 and saw strong results for under-fives — around 84% screened and 77% started on preventive medicine - but have been working to improve results for over-5s.

Other work. We also had early success in helping secure child-friendly medicine for Pakistan. More recently, we’ve also been supporting the Pakistani governments with strategic planning for the next Global Fund grant. Looking ahead, we’re aiming to work with the largest province in Pakistan, Punjab, providing technical assistance to its new community health worker program to embed our model in their TB work.

There’s more detail on all of this work in the appendix below.

The next opportunity: all of Sindh

The US government is withdrawing its funding for community TB contact tracing across 15 districts of Sindh at the end of July, which would leave thousands of people without a TB contact-tracing service in the community.

The Sindh government has invited us to expand our work in Sindh. We’d work in those 15 districts, plus 8 that were never covered, on top of our current 7 — reaching all 30 districts of the province.

If we can cover all of Sindh, we'd go from serving around 6,000 TB patients a year to around 35,000. Based on our own modelling, that would mean roughly 285 lives a year potentially saveable across the full 30 districts, at an estimated ~$5k per life saved — roughly 10× GiveWell's benchmark.

We want to move quickly so communities aren't left without community based screening for too long. We're currently running an implementation-partner selection process and hiring a local Sindh lead to manage partners on the ground, while raising the funds we'll need to sign a grant agreement.

We’re fundraising for an urgent $512k now

Our immediate target is $512k by ~end of July. We want to sign with implementation partners asap. But we’ll need money in the bank to cover a 6 month grant at the point we sign. $512k is the most time-critical part of what we need. We are planning on speaking with institutional funders but we don’t have time to receive larger grants in this timeframe so we need individual donors to get this off the ground.

If we don’t get the money fast enough we’ll likely have to delay signing with new partners which will mean communities have a larger gap before contact tracing resumes, we might also lose potential staff who could carry over into this program.

Here’s a two pager document with our fundraising ask (similar to this post)

Our total gap is $1.8m for 2026-2027 which I’m hoping to raise from institutional funders over a longer time frame.

As I write this we have started to receive donations to fill that gap, if you’re interested in an up to date picture of the remaining gap please do reach out. Likewise if you'd like to see the full budget.

Risk and uncertainties

There are some things we’re less sure of as we expand:

• Execution risk in a fast scale-up. Going from 7 to 30 districts is a big jump in execution - we’ll be working with a new partner for ~half the districts and we need to massively scale up our monitoring to ensure quality at scale. We’re planning to scale up in phases and starting with biggest hospitals in the district first. But it will still be a lot to manage and maintain quality.
• Dependence on external stakeholders. The timeline, permissions and alignment with stakeholders on the ground are only partly in our control. In this expansion will have a renewed emphasis on getting over-5s referred to hospitals and screened there - but it remains to be seen how well we can get that referral link to operate across a large number of hospitals.
• Uncertainties in cost-effectiveness. Our own estimates are very uncertain and rely on modelled benefits beyond just preventing TB cases in under-5s. You might want to trust GiveWell’s model over ours.
• Key-person risk. Spiro still leans heavily on me - Habiba - the CEO. I'm trying to build out the team but that takes time.
• Ceiling for this intervention. This intervention focuses on a specific population of kids living in houses where there is already TB. Even if we expand to other countries too I suspect this intervention maxes out reaching low hundreds of thousands a year not millions.

How to give

Spiro is fiscally sponsored by Players Philanthropy Fund, Inc (a 501(c)(3) Federal Tax ID: 27-6601178) so donations are tax deductible in the US.

You can donate directly on our Cornerstone page.

For larger gifts, you can make a direct wire or ACH or donate from a DAF - message me and I can share details.

The future for Spiro

I’m hugely grateful for everyone who supported or donated so far to get us here. I think the next few months are going to be a lot of work to expand so fast but I’m excited to do it. Thank you to everyone for reading and please do reach out if you have questions or if you’d like to support.

Appendix: More on what we've done since Spiro’s launch

Focused on Pakistan. Rox Heston and I launched Spiro in November 2023. In early 2024, we selected Pakistan as the first country to work in - it has a high TB prevalence (669k cases per year), and particularly low coverage of TB preventive therapy especially for under-5s (4%) but a commitment to ambitious 90% TPT coverage targets in strategic plans that flow from the global End TB Strategy. We also focused on the public sector as private sector hospitals had more support.

First pilot. In late 2024 we ran our first program as a feasibility pilot at the Federal Government TB Centre in Rawalpindi, partnering with a local NGO MALC who delivered on the ground. It was a TB specialist hospital but didn’t currently offer services for kids under-5. Our pilot followed a cohort of 167 people with TB and the ~950 people who lived with them over 3 months. Our TB Shield model was able to screen 89% of kids under-5 and practically all of them started the preventive medicine when offered at a cost of under $20 per person screened. This was our pilot write up and some more details here. We extended the program after the pilot and it has been running continuously since.

Supported medicine procurement. We also supported the Pakistani National TB program to secure 10,000 courses of brand new child-friendly TB preventive treatment - only 12 doses vs 182 doses per course, and it dissolves in water so it’s easy to take. Spiro helped with submitting an application and updating national guidelines and training.

GiveWell grant. Following our pilot results, and GiveWell’s own research into the intervention and grant for a similar program delivered by CHAI in India, GiveWell recommended a $247,118 grant to fill our 2025 funding gap. Their write-up estimated our 2025 programming at around 8× their benchmark. Our intention for growth was focused mostly on Pakistan’s largest province, Punjab. The second largest province Sindh already had more external support at this point.

Expanded into Sindh province. However, 2025 saw huge changes in international donor funding causing a lot of disruption for NGOs and governments. We were glad to be in a position to speak with the Sindh government to discuss how we could partner together. In September 2025, we launched TB Shield in 19 more public hospitals across 7 districts of Sindh, this time working with local implementer Metrics Research. We also engaged another partner Momentum for M&E and hired our first local team member in Pakistan. Unfortunately, due to some concerns about drug supply, we paused field activities for ~3 months.

We relaunched in January 2026, this time using the new child-friendly medicine. Once it got going again it was great to see the program operate at larger scale - across 19 hospitals we reached more children in a couple of months than in our first 18 months at a single hospital. As in our pilot, we again saw strong results for under-fives — around 84% screened and 77% started on preventive medicine. It has been encouraging to see that similar results hold up from our pilot in a range of rural and urban settings.

However over-5 screening rates haven’t held up. In contrast to our first program, we weren’t placing staff full-time at the hospitals to keep costs lower and initially there wasn’t a programmatic focus on over-5s - you can see more in the write up. The results for over-5s have notably improved since then driven by 1-2 of the bigger hospitals performing better but I don’t think we’ve cracked consistent performance at hospitals when we don’t have our own staff there consistently.

Supporting strategic planning. As we built a track record and engaged a strategic consultant with strong networks and TB experience in Pakistan, we were better positioned to offer support to government on their TB planning. In the last few months our team has been supporting the Sindh government on their strategic planning including offering suggestions on contact screening.

Pitching TA support. We continue to work on the larger province Punjab too. However, in mid 2025 we learned about a new flagship community health worker program across the province which would have TB in its remit. We pivoted from pitching to deliver a program ourselves (“direct delivery”) to instead offering to provide technical assistance to this program to help them adopt our TB Shield model, working with our partner SPHERE Consulting. Progress on this project has been incremental. So far, we’ve contributed content to the TB chapter of the handbook for the new community workers and recently presented to the Secretary of Health. We are currently working on launching Phase 1 training in the government’s first 4 pilot districts.

Leadership shift. Having helped build Spiro to this point my co-founder Rox Heston decided to move on from Spiro and onto her next challenge. The first year of Spiro - working out what we were and what we would do - was full of a lot of uncertainties and I’m really grateful to have had Rox to work it out with me. By the time she left, we had built substantial programs helping real kids in Pakistan. We were able to have a smooth quarter of handover to me taking on the sole CEO role.

Other fun things. We’ve had two paper abstracts accepted to the World TB conference in Rio this November, sharing results from our first hospital and the Sindh program. Before you ask - yes we have reached out to John Green and we did get to chat to him about all things Spiro and TB!